Health inspection·September 12, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not provide the necessary care and services for 1 of 2 sample residents (Resident 1) who had a fall by failing to:1. Ensure Resident 1's fall assessment was accurate and complete.2. Ensure Resident 1's fall was thoroughly investigated by interviewing the roommate.3. Ensure Resident 1's Care Plan was resident centered.4. Ensure Resident 1's Minimum Data Set (MDS) was accurate to reflect the resident needs for Activities of Daily Living (ADL - activities such as bathing, dressing and toileting a person performs daily).5. Ensure LVN 1 reported and monitored Resident 1 after a suspected fall.6. Ensure Resident 1's fall was monitored and documented on 8/31/2025 11pm to 7am shift, 9/1/2025 3pm to 11pm shift and 11pm to 7am shift, 9/2/2025 3pm to 11am shift and 11pm to 7am shift.This deficient practice has the potential for Resident 1 to have further falls which could result to harm, hospitalization, and/or death.Findings:1. During a review of Resident 1's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE], and was readmitted on [DATE] with the following, but not limited to, diagnoses of Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), muscle weakness, dry eye syndrome (eye is dry and sensitive to light), dementia (a progressive state of decline in mental abilities), difficulty in waking, history of falling and hypertension (HTN-high blood pressure).During a review of Resident 1's Physician Orders, dated 11/21/2024, the Physician Orders indicated clonidine hydrochloride (antihypertensive medication) oral tablet 0.1 milligrams (mg) as needed for systolic (pressure in arteries when heart pumps blood throughout body) greater than 160.During a review of Resident 1's Care Plan with focus on diagnosis of dementia, dated 12/3/2024, the Care Plan indicated staff are to perform ADLs every shift.During a review of Resident 1's Care Plan with focus on Resident 1 at risk for decline in ADLs secondary but not limited to Parkinson's Disease with dyskinesia, cataracts and dementia, dated 3/5/2025, the Care Plan indicated to assist with ADL to the extent necessary for safety and comfort. During a review of Resident 1' s MDS, dated [DATE], the MDS indicated the resident is severely impaired in cognitive (the ability to think and understand) skills for daily decision making.During a review of Resident 1's Fall Risk Assessment, dated 6/5/2025, the assessment indicated only the age category was marked.During a concurrent interview and record review on 9/12/2025 at 11:45AM, Resident 1's Fall Risk Assessment, dated 6/5/2025, was reviewed. The DON stated the Fall Risk Assessment was not accurate and was incomplete because vision and cognitive should have been marked.During a concurrent interview and record review on 9/12/2025 at 12:13PM, Resident 1's Fall Risk Assessment, dated 6/5/2025 and 9/5/2025, were reviewed. The DON stated the fall risk assessments are inaccurate and the assessments should have included the resident's antihypertensive medication, unsteady gait, visual due to cataracts, and altered awareness should have been marked which places the resident at a high risk for falls.During a review of the facility's P&P titled Charting and Documentation, Page 1 of 3 056063 056063 09/12/2025 Infinity Care of East Los Angeles 101 S Fickett Street Los Angeles, CA 90033

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revised 3/2024, the P&P indicated documentation in the medical record will be objective, complete and accurate. 2. During a review of Resident 2's (Resident 1's roommate) admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the following but not limited to diagnosis of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 2's History and Physical (H&P), dated 9/10/2024, the H&P indicated the resident has the capacity to understand and make decisions.During a review of Resident 2's MDS, dated [DATE], the MDS indicated the resident is independent in cognitive skills for daily decision making.During an interview on 9/11/2025 at 10:53AM while in Resident 1 and Resident 2's room, Resident 2 was observed lying on her left side in bed and facing Resident 1's bed, when Resident 2 stated she observed Resident 1 having a fall at the end of 8/2025. Resident 2 also stated Resident 1 slipped from her bed and fell on her buttocks.During an interview on 9/11/2025 at 11:10AM, Resident 1 stated she fell from her bed a few weeks ago. Resident 1 also stated her roommate witnessed her fall.During a concurrent interview and record review on 9/12/2025 at 11:40AM, Resident 1's Skin Incident and Investigation Report, dated 9/1/2025, was reviewed. DON stated she did not but should have had an interview with Resident 2. The DON also stated she did not do a thorough investigation.During an interview on 9/12/2025 at 12 PM, the DON stated she forgot to interview Resident 2 when she did her investigation. The DON also stated interviewing Resident 2 would help clarify if the resident had an alleged fall or an actual fall.During a review of the facility's P&P titled Assessing Falls and Their Causes, revised 3/2024, the P&P indicated after an observed or probably fall, clarify the details of the fall, such as when the fall occurred and what the individual was trying to do at the time the fall occurred. The P&P also indicated to evaluate chains of events or circumstances preceding a recent fall including whether the resident was among other persons.3. During a review of Resident 1's Care Plan, with a focus on Resident 1, being at risk for decline in ADLs secondary but not limited to Parkinson's Disease with dyskinesia, cataracts and dementia, dated 3/5/2025, the Care Plan indicated the following: Assist with ADL's to the extent necessary for safety and comfort. Call light and frequently used items at reach. Encourage resident to do ADLs that do not need assistance from staff. Labs and medications as ordered. Monitor Residents ADLs daily. PT/OT/ST services if needed. Report to MD if sudden changes in ADLs occur. RNA services as ordered.During a concurrent interview and record review on 9/12/2025 at 2PM, Resident 1's Care Plans, with a focus on decline in ADLs, dated 3/5/2025, were reviewed. The DON stated the care plan was not and should be resident centered for the continuity of care of the residents and to prevent falls.During a review of the facility's P&P titled Comprehensive Person-Centered Care Plan, revised 3/2024, the P&P indicated a comprehensive, person-centered care plan that includes measurables objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident.4. During a review of Resident 1's MDS, dated [DATE], the MDS indicated the resident is independent (Resident completes the activity by themselves with no assistance from a helper) with rolling left and right, sitting to lying, lying to sitting on the side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, walk 10 feet, walk 50 feet with two turns and walk 150 feet.During a review of Resident 1's Occupational Therapy Certification (OTC), dated 6/3/2025, the OTC indicated the resident required Contact Guard Assistance (CGA - maintains physical contact with a patient, often with one or two hands on their body, to provide balance and stability during an activity) with roll to left, roll to right, supine (lying) to sit, sit to supine, sit to stand, stand to sit and wheelchair mobility.During a review of Resident 1's Physical Therapy Certification (PTC), dated 6/05/2025, the PTC indicated the resident required moderate 056063 Page 2 of 3 056063 09/12/2025 Infinity Care of East Los Angeles 101 S Fickett Street Los Angeles, CA 90033

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assistance (the resident performs half of the work while the Physical Therapist completes the other half of the work) with roll to left, roll to right, supine (lying) to sit, sit to supine, wheel chair mobility, brakes management, sit to stand, stand to sit, bed to wheelchair, wheelchair to bed, and gait on level surfaces.During a concurrent interview and record review on 9/12/2025 at 2:11PM, Resident 1's MDS, dated [DATE], and Resident 1's Physical Therapy Certification (PTC), dated 6/5/2025, were reviewed. The MDS coordinator stated the MDS is not accurate, therefore, the PTC and MDS are not consistent, and it should be. The MDS coordinator also stated Resident 1 is at risk of falls and would require some supervision and the MDS should indicate Resident 1 required assistance.During a review of the facility's P&P titled Charting and Documentation, revised 3/2024, the P&P indicated Documentation in the medical record will be objective, complete and accurate.5. During an interview on 9/11/2025 at 11:45AM, Resident 1's Responsible Party (RP) stated Resident 1 informed RP of the fall on 8/31/2025. RP also stated she had informed Licensed Vocational Nurse 1 (LVN 1) on 8/31/2025 of Resident 1's fall. The RP stated she made the Director of Nursing (DON) aware of Resident 1's fall on 9/1/2025.During an interview on 9/11/2025 at 12:36PM, LVN 1 stated the RP informed him of Resident 1's fall. LVN 1 also stated because Resident 1 stated she did not fall; LVN 1 does not need to do anything else.During an interview on 9/11/2025 at 1:53PM, the DON stated when a resident is suspected of a fall, an investigation would be needed to determine the fall.During an interview and record review on 9/12/2025 at 11:37AM, LVN 1's Counseling Record, dated 9/1/2025, was reviewed. The DON stated LVN 1 was written up and was provided education for the lack of reporting and monitoring of Resident 1's alleged fall. During a review of the facility's P&P titled Assessing Falls and Their Causes, revised 3/2024, the P&P also indicated if an assessment rules out significant injury, help the resident to a comfortable sitting, lying, or standing position, and then document relevant details. The P&P also indicated to notify the following individuals but not limited to the nurse supervisor on duty and the DON.During a review of the facility's P&P titled Investigating Resident Injuries, revised 3/2024, the P&P indicated if an incident/accident is suspected, a nurse or nurse supervisor completes the facility-approved accident/incident form.During a review of the facility's P&P titled Change in a Resident's Condition and Status, revised 3/2024, the policy indicated the nurse will record in a resident's medical record information relative to changes in the resident's medical/mental condition or status.During a review of the facility's P&P titled Safety and Supervision of Residents, revised 3/2024, the P&P indicated employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents.6. During a concurrent interview and record review on 9/12/2025 at 1:51PM, Resident 1's Progress notes, dated 8/31/2025 to 9/2/2025, were reviewed. The DON stated there is no monitoring for Resident 1's fall other than 8/31/2025 for 3pm-11pm shift and 9/1/2025 for the 7am-3pm shift. The DON also stated there should be documentation on monitoring Resident 1 for 8/31/2025 11pm to 7am shift, 9/1/2025 3pm to 11pm shift and 11pm to 7am shift, 9/2/2025 3pm to 11pm shift and 11pm to 7am shift.During a review of the facility's Policy and Procedure (P&P) titled Fall and Management of Fall Risk, revised 3/2024, the P&P indicated the staff will monitor and document responses to interventions intended to reduce falling or the risk of falling for the resident who experienced a fall.During a review of the facility's P&P titled Assessing Falls and Their Causes, revised 3/2024, the P&P indicated when a resident falls, documentation includes, but not limited to, assessment data, interventions, completion of fall risk assessment, and signature and title of person documenting. 056063 Page 3 of 3